An adult with a disability may be discharged from the acute care setting where they received treatment or were quarantined for COVID-19 illness, but required additional lower-acuity care. In this case, they may transition to a temporary care setting prior to returning home, such as a nursing home, an alternate care site, or a hospital swing bed. Examples of promising practices for person-centered discharge planning using the CMIST Framework are outlined in the table below. This is not an exhaustive list of care coordination practices. It is unlikely that every consideration described below will apply to an individual’s discharge plan. For individuals with intellectual and developmental disabilities who use decision-making supports, the discharge planning process should include input from their support system. The applicable considerations and the individual’s specific needs should be communicated to the temporary care setting to which the individual is being transferred.
Communication
The Individual… | Your discharge planning process should… |
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…has limited English proficiency (LEP) | |
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…is deaf, hard of hearing, or is unable to fully use verbal speech. | - Provide an ASL translator, either in-person or virtually
- Have written materials to convey necessary information in plain language or use two-way texting devices
- If other auxiliary speech or hearing devices, such as hearing aids, are needed, ensure the individual has access to functioning devices
- Acquire specialty PPE (if needed) such as clear face masks to facilitate lip reading
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...is blind or vision impaired | - Provide written materials in Braille and/or through spoken word
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Maintaining Health
The Individual… | Your discharge planning process should… |
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…has one or more chronic conditions | |
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…requires infection prevention measures | - Facilitate access to PPE for both the individual and direct service workers (DSWs; if applicable) to reduce the risk of infection
- Provide regular screening for COVID-19, and testing for the individual and DSWs (if appropriate)
- If the individual is discharged while still COVID+ follow the CDC Guidance on
Disposition of Patients with SARS-CoV-2 Infection
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…requires nutrition services | - Document the dietary and nutritional needs of the individual, including cultural-appropriate needs to inform the temporary care site
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Independence
The Individual… | Your discharge planning process should… |
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…has a service animal | - Ensure the service animal can be housed with this individual in their new setting
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…requires DME | |
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| …uses alternate strategies to maintain independence | - Discuss and plan with the individual for alternative forms of support such as access to picture cue cards or a daily schedule
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Support
The Individual… | Your discharge planning process should… |
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…has been separated from family or caregivers due to social distancing requirements | - The individual may experience increased anxiety or other psychological distress and therefore need additional behavioral health supports that are delivered in an accessible, culturally competent manner
- For social programs and technologies, see the
Aging and Disability Resource Centers (ADRCs) / No Wrong Door System, or other local coordinating entity. If visitation is allowed, ensure the individual has opportunities to see their family or caregivers in a manner consistent with infection prevention measures
- If visitation is not allowed, provide technology and technological assistance (if needed) to facilitate virtual visits
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| …will be discharged home or to another care setting | - Clearly state the indicators for when they can be safely discharged to help prevent unnecessarily long stays or institutionalization
- The individual may experience increased anxiety or other psychological distress from changes in physical environment. Discuss and plan with the individual and support system the additional behavioral health supports needed
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